Inpatient Workup and Management for Newly Diagnosed Heart Failure

Immediate Clinical Assessment

• The American College of Cardiology and the European Heart Journal recommend assessing volume status systematically, including checking for jugular venous distension, hepatojugular reflux, peripheral edema, pulmonary rales, and third heart sound (S3 gallop) 1, 2, 3
• The American College of Cardiology recommends measuring orthostatic blood pressure changes to evaluate volume status and guide diuretic therapy 1, 2
• The American College of Cardiology and the European Heart Journal recommend documenting weight, height, and calculating BMI as baseline for monitoring response to therapy 1, 2
• The American College of Cardiology recommends evaluating functional capacity, including assessing the patient's ability to perform activities of daily living and quantifying dyspnea severity 1, 2
• The American College of Cardiology recommends obtaining a detailed substance use history, including asking about alcohol consumption, illicit drug use, chemotherapy exposure, and alternative therapies that may be cardiotoxic 2, 4

Essential Diagnostic Testing

• The American College of Cardiology and the European Heart Journal recommend performing a 12-lead ECG to assess for arrhythmias, conduction abnormalities, left ventricular hypertrophy, or evidence of prior myocardial infarction 1, 2, 3, 4, 7
• The American College of Cardiology recommends performing a chest X-ray (PA and lateral views) to look for cardiomegaly, pulmonary venous congestion, interstitial edema, pleural effusions, and Kerley B lines 1, 2, 4, 7
• The American College of Cardiology and the European Heart Journal recommend performing two-dimensional echocardiography with Doppler to determine left ventricular ejection fraction (LVEF), assess left ventricular size, wall thickness, and regional wall motion abnormalities, and evaluate valve function 1, 2, 4, 5, 6
• The American College of Cardiology recommends measuring BNP or NT-proBNP if diagnosis remains uncertain after initial evaluation 2, 4, 6

Coronary Artery Disease Evaluation

• The American College of Cardiology recommends assessing for coronary artery disease as the underlying etiology, especially in patients with chest pain or anginal symptoms, and considering coronary angiography unless there are contraindications to revascularization 1, 2, 8
• The American College of Cardiology recommends considering troponin I or T if there's any suspicion of acute coronary syndrome 7

Immediate Therapeutic Management

• The American College of Cardiology recommends initiating loop diuretics (furosemide) for symptomatic relief of bilateral edema and congestion, and monitoring daily weights, strict intake/output, and clinical signs of decongestion 6
• The American College of Cardiology recommends monitoring renal function and electrolytes closely during diuresis, especially potassium and magnesium 1, 2, 4

Additional Testing in Selected Circumstances

• The American College of Cardiology recommends considering screening for hemochromatosis, HIV testing, rheumatologic panel, sleep study, and endomyocardial biopsy in specific circumstances 2, 4, 6, 8

Critical Pitfalls to Avoid

• The American College of Cardiology and the European Heart Journal recommend not delaying echocardiography, as it is the definitive test to confirm heart failure and guide therapy 1, 2, 5
• The American College of Cardiology recommends not assuming the diagnosis without objective evidence, and considering reversible causes such as peripartum cardiomyopathy, viral myocarditis, thyroid disease, alcohol-induced cardiomyopathy, or undiagnosed valvular disease 2, 3, 4, 5